Depression, anxiety and their

comorbidity in the Swedish general

population: point prevalence and the
efect on health-related quality of
life
Robert Johansson1, Per Carlbring2, A sa Heedman1, Bjorn Paxling1 and
Gerhard Andersson1,3,4

Department of Behavioural Sciences and Learning, Linkoping University, Linkoping, Sweden

Department of Psychology, Stockholm University, Stockholm, Sweden
Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Stockholm,
Sweden
4 Swedish Institute for Disability Research, Linkoping University, Linkoping, Sweden
1
2
3

ABSTRACT

Background. Depression and anxiety disorders are major world-wide problems.

There are no or few epidemiological studies investigating the prevalence of
depression,
generalized anxiety disorder and anxiety disorders in general in the Swedish
population.
Methods. Data were obtained by means of a postal survey administered to 3001
randomly selected adults. After two reminders response rate was 44.3%. Measures
of depression and general anxiety were the 9-itemPatient Health Questionnaire
Depression
Scale (PHQ-9) and the 7-itemGeneralized Anxiety Disorder Scale (GAD-7).
The PHQ-9 identified participants who had experienced clinically significant
depression
(PHQ-9 _ 10), and who had a diagnosis of major depression (defined by using
a PHQ-9 scoring algorithm). Clinically significant anxiety was defined as having a
GAD-7 score _ 8. To specifically measure generalized anxiety disorder, the
Generalized
Anxiety Disorder Questionnaire-IV (GAD-Q-IV) was used with an established
cut-of. Health-related quality of life was measured using the EuroQol (EQ-5D).
Experiences of treatments for psychiatric disorders were also assessed.
Results. Around 17.2% (95% CI: 15.119.4) of the participants were experiencing
clinically significant depression (10.8%; 95% CI: 9.112.5) and clinically significant
anxiety (14.7%; 95% CI: 12.716.6). Among participants with either clinically
significant
depression or anxiety, nearly 50% had comorbid disorders. The point prevalence
of major depression was 5.2% (95% CI: 4.06.5), and 8.8% (95% CI: 7.310.4) had
GAD. Among those with either of these disorders, 28.2% had comorbid depression
and GAD. There were, generally, significant gender diferences, with more women
having a disorder compared to men. Among those with depression or anxiety, only
between half and two thirds had any treatment experience. Comorbidity was
associated
with higher symptomseverity and lower health-related quality of life.
Conclusions. Epidemiological data from the Swedish community collected in this
study provide point prevalence rates of depression, anxiety disorders and their

comorbidity. These conditions were shown in this study to be undertreated and

How to cite this article Johansson et al. (2013), Depression, anxiety and their comorbidity in the Swedish general population:
point
prevalence and the efect on health-related quality of life. PeerJ 1:e98; DOI 10.7717/peerj.98

associated with lower quality of life, that need further eforts regarding preventive
and treatment interventions.
Subjects Epidemiology, Psychiatry and Psychology, Public Health
Keywords Depression, Anxiety, Generalized anxiety disorder, Prevalence, Health-related

quality
of life

INTRODUCTION
Depression and anxiety disorders are major world-wide health problems that afect
a substantial number of individuals every year (Ebmeier, Donaghey & Steele, 2006;
Kessler, Merikangas & Wang, 2007). In the US National Comorbidity Survey
Replication
(NCS-R), lifetime prevalence of mood and anxiety disorders were 20.8% and 28.8%,
respectively (Kessler, Merikangas & Wang, 2007). Twelve-month prevalence
estimates of
mood and anxiety range from 6.6% to 11.9% and 5.6% to 18.1% across surveys
from
Europe, Australia and the US (Baumeister & Harter, 2007). In Sweden in 1957, the
point
prevalence of depression was estimated to be 4.7%, based on data fromthe total
population
(n D 2612) of Lundby, a small rural area in southern Sweden (Rorsman et al., 1990).
Using
the national Swedish Twin Registry, lifetime prevalence for depression was
estimated to be
13.2% among men and 25.1% among women (Kendler et al., 2006). In the Lundby
study,
lifetime prevalence for depression was 27% among men and 45% among women,
when
participants were followed from 1957 up to 1972 (Rorsman et al., 1990).
Importantly, the
Lundby study did not use DSM criteria for major depression, which makes
comparisons
to prevalence rates from other countries complicated (Rorsman et al., 1990). To our
knowledge, there exist no up-to-date point estimates of DSM-IV depression from the
Swedish general population.
For anxiety disorders, there is a 12-month prevalence study from the Swedish
general
population regarding panic disorder (2.2%; Carlbring et al., 2002) and a point
prevalence
study on social phobia (15.6%; Furmark et al., 1999). In the NCS-R, the 12-month
prevalence for these disorders were 2.7% and 6.8%, respectively (Kessler et al.,
2005). From
Sweden, there exist point prevalence data on generalized anxiety disorder (GAD)
from
primary care (3.6%; Allgulander & Nilsson, 2003;Munk-Jrgensen et al., 2006). This
can be

compared to NCS-R, where 12-month prevalence of GAD was 3.1% (Kessler et al.,
2005).
However, the point prevalence of GAD in the general Swedish population seems
unknown.
Comorbidity between mood and anxiety disorders is known to be common. For
example, among participants in the NCS-R that had a diagnosis of major depression,
57.5% also met criteria for at least one anxiety disorder (Kessler, Merikangas &
Wang,
2007). Other epidemiological data suggests that 59.0% of individuals with GAD
fulfill
criteria for major depression (Carter et al., 2001). This suggests that comorbidity
between
depression and anxiety disorders is the rule rather than the exception. Comorbidity
has consistently been associated with a poorer prognosis and greater demands for
professional help (Albert et al., 2008; Schoevers et al., 2005). In addition,
comorbidity
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 2/18

between depression and anxiety seems strongly associated both with role
impairment and
higher symptomseverity (Kessler et al., 2003). Generally, psychiatric comorbidity is
known
to afect various aspects of health-related quality of life (Carpentier et al., 2009;
Saarni et al.,
2007; Sherbourne et al., 2010).
The aim of the present study was to investigate the point prevalence of depression,
GAD,
anxiety disorders in general, and comorbidity in a representative Swedish
sample.We also
investigated the efect of depression, anxiety and comorbidity on health-related
quality of
life.

MATERIALS & METHODS

This study was carried out in accordance with the STROBE initiative for reporting
epidemiological data (Von Elm et al., 2007). Approval for the study was obtained
from
the Institutional Review Board at the Department of Behavioural Sciences and
Learning,
Psychology Section, Linkoping University, Sweden. By responding to the postal
survey,
participants gave their consent to take part in the study.

Sample and data collection

Data collection was conducted in the autumn of 2009. A total of 3001 participants
aged
1870 years were randomly selected from the Swedish population and address
register
(SPAR). This register includes all persons who are registered as residents in Sweden,
both
Swedish and non-Swedish citizens. Systematic sampling with a randomly chosen
starting

point and a fixed interval was used as sampling technique. The researchers
conducting the
study were not involved in the sampling.
A questionnaire (described below) was mailed by surface mail to each participant
(n D 3001), together with a stamped return envelope. There was also an
explanatory letter,
in which the study was described. A web version of the survey was also constructed
and all
participants could choose between the paper survey and the web survey.
Participants were
also informed that anonymity was guaranteed and that all data collected were to be
used for
research purposes only. About two weeks after initially sending the letters,
questionnaires
and stamped return envelopes were sent out to participants who had not yet
responded
(n D 2175). Thirty-nine participants could not be reached by mail and their
questionnaires
were returned undelivered. In addition, two questionnaires were returned because
of
insufcient knowledge of Swedish. A total of 1329 (44.3%) responded and were
eligible for
analysis. Forty-two of these questionnaires were returned using the Internet version
of the
survey. In cases where a participants response had missing values, all available
data were
used as long as a complete score (e.g., the total score for an instrument) could be
calculated.
Details of attrition can be found in Tables 13. Among those who responded, mean
age was
46.2 years (SD D 14:5) and 745 participants (56.1%) were female. Fifty-two percent
had
post-secondary education.

Questionnaire design and measures of mental health

The survey contained questions about demographics and treatment history.

Moreover,
the survey contained established measures of depression, general anxiety, GAD and
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 3/18
Table 1 Demographic description of the participants.
Male Female Total Test statistics
Age Mean (SD) 46.6 (14.3) 45.9 (14.6) 46.2 (14.5) t.1193/ D 0:868, p D :39
MinMax 1868 1868 1868
Marital status Married or co-habiting 424 (72.9%) 549 (74.2%) 973 (73.6%) _2.N D 1322;df D 1/ D 0:30,
p D :58
Single 158 (27.1%) 191 (25.8%) 349 (26.4%)
Having children Yes 436 (74.7%) 572 (76.8%) 1008 (75.8%) _2.N D 1329;df D 1/ D 0:80,
p D :37
Educational level Primary 98 (18.0%) 99 (13.9%) 197 (15.7%) _2.N D 1256;df D 3/ D 15:7,
p < :001
Secondary 199 (36.6%) 211 (29.6%) 410 (32.6%)
Post-secondary 02, 9 years 90 (16.6%) 144 (20.2%) 234 (18.6%)
Post-secondary 3+ years 156 (28.7%) 259 (36.3%) 415 (33.0%)
Experiences of treatment for

worrying
Yes 76 (13.1%) 164 (22.3%) 240 (18.3%) _2.N D 1314;df D 1/ D 18:1,
p < :001
Experiences of any treatment
for psychiatric problems
Yes 91 (15.7%) 197 (26.7%) 288 (21.9%) _2.N D 1315;df D 1/ D 22:9,
p < :001
Table 2 Prevalence estimates.
Definition Male Female Total Test statistics
Clinically significant depression or anxiety
Depression PHQ-9 _ 10 8.3%
(6.010.5)
12.9%
(10.415.4)
10.8%
(9.112.5)
_2.N D 1240;df D 1/ D 6:8,
p < :01
Anxiety GAD-7 _ 8 10.7%
(8.113.2)
17.9%
(15.120.7)
14.7%
(12.716.6)
_2.N D 1266;df D 1/ D 13:0,
p < :001
Comorbid depression and anxiety PHQ-9 _ 10 and
GAD-7 _ 8
5.7%
(3.87.7)
10.5%
(8.112.8)
8.3%
(6.89.9)
_2.N D 1201;df D 1/ D 8:8,
p < :01
Any disorder PHQ-9 _ 10 and/or
GAD-7 _ 8
13.3%
(10.416.1)
20.5%
(17.423.6)
17.2%
(15.119.4)
_2.N D 1201;df D 1/ D 10:8,
p < :001
Major depression or Generalized anxiety disorder
Major depression PHQ-9 algorithm 3.4%
(1.94.9)
6.7%
(4.88.6)
5.2%
(4.06.5)
_2.N D 1240;df D 1/ D 6:82,
p < :01
GAD GAD-Q-IV _ 5.7 6.6%
(4.68.7)
10.6%
(8.312.8)
8.8%
(7.310.4)

_2.N D 1269;df D 1/ D 6:13,

p < :05
Comorbid major depression and GAD PHQ-9 algorithm and
GAD-Q-IV _ 5.7
2.2%
(1.03.5)
3.8%
(2.35.3)
3.1%
(2.14.1)
_2.N D 1195;df D 1/ D 2:4;ns
Any disorder PHQ-9 algorithm and/or
GAD-Q-IV _ 5.7
8.0%
(5.710.3)
13.4%
(10.816.0)
11.0%
(9.212.7)
_2.N D 1195;df D 1/ D 8:8,
p < :01
Notes.
95% confidence intervals are given in parenthesis. PHQ-9: 9-item Patient Health Questionnaire Depression Scale;
GAD-7: 7-item Generalized Anxiety Disorder Scale;
GAD-Q-IV: Generalized Anxiety Disorder Questionnaire-IV.

Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 4/18

Table 3 EuroQol (EQ-5D) distribution (percentage) of respondents reporting no problems,
moderate or severe problems in diferent dimensions,
by gender.
EQ-5D dimension Male Female Total Test statistics
Mobility No problem 548 (94.3%) 680 (92.6%) 1228 (93.4%) _2.N D 1315;df D 2/ D 1:50;ns
Moderate 32 (5.5%) 52 (7.1%) 84 (6.4%)
Severe 1 (0.2%) 2 (0.3%) 3 (0.2%)
Self-care No problem 572 (98.5%) 729 (98.8%) 1301 (98.6%) _2.N D 1319;df D 2/ D 1:57;ns
Moderate 6 (1.0%) 8 (1.1%) 14 (1.1%)
Severe 3 (0.5%) 1 (0.1%) 4 (0.3%)
Usual activities No problem 546 (94.0%) 657 (89.4%) 1203 (91.4%) _2.N D 1316;df D 2/ D 11:0, p < :01
Moderate 28 (4.8%) 71 (9.7%) 99 (7.5%)
Severe 7 (1.2%) 7 (1.0%) 14 (1.1%)
Pain/discomfort No problem 372 (64.2%) 430 (58.7%) 802 (61.1%) _2.N D 1312;df D 2/ D 5:71;ns
Moderate 190 (32.8%) 268 (36.6%) 458 (34.9%)
Severe 17 (2.9%) 35 (4.8%) 52 (4.0%)
Anxiety/depression No problem 422 (72.8%) 440 (60.0%) 862 (65.7%) _2.N D 1313;df D 2/ D 23:4, p
< :001
Moderate 143 (24.7%) 268 (36.6%) 411 (31.3%)
Severe 15 (2.6%) 25 (3.4%) 40 (3.0%)

health-related quality of life (HRQoL). These measures are described below. In total,
there
were 28 questions in the survey. A mistake in the questionnaire design made the
question
regarding educational level impossible to interpret whether answers were given for
ongoing
or completed education.
Depressive symptoms
Symptoms of depression were measured using the 9-item Patient Health
Questionnaire
Depression Scale (PHQ-9; Kroenke, Spitzer & Williams, 2001). The PHQ-9 contains 9
items, with a total score ranging from 0 to 27, where each item is scored 0 to 3 (0:
Not

at all; 1: Several days; 2: More than half of the days; 3: Nearly every day). Total
scores
of 04 indicate no depression, 59 mild depression, 1014 moderate depression, 15
19
moderately severe depression and 2027 severe depression (Kroenke, Spitzer
&Williams,
2001). Psychometric properties for the PHQ-9 have been shown to be good, with an
internal consistency in the range Cronbachs _ D :86:89 and a test-retest reliability
of
r D :84 (Kroenke et al., 2010). As the nine items correspond to the DSM-IV criteria
for
depression, the PHQ-9 can be used with a diagnostic algorithm to ascertain a
probable
diagnosis of major depression. A diagnosis is made if five or more of the nine
depressive
symptoms are reported to be present (defined as having an item score of _ 2), and
one of
the symptoms is anhedonia or depressed mood (having a score of _ 2 on question 1
or 2).
Another way of detecting depression is to use a cut-of score. A PHQ-9 score of _ 10
is
an established cut-of and seem to be the optimal balance between sensitivity
(88%) and
specificity (88%) when detecting depression (Kroenke, Spitzer&Williams, 2001). The
more
strict PHQ-9 score of _ 15 yields a higher specificity (95%), but lower sensitivity
(68%)
(Kroenke, Spitzer&Williams, 2001).
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 5/18

The PHQ-9 has been shown to be a valid instrument when measuring current
depression in the general population (Kroenke et al., 2009). It has also been used to
provide prevalence estimates in population-based studies conducted in Germany
(Martin
et al., 2006), Australia (Pirkis et al., 2009) and Canada (Patten & Schopflocher,
2009).
All these studies used the diagnostic algorithm mentioned above, and the study by
Pirkis et al. (2009) did also describe prevalence rates using the PHQ-9 cut-of score
10.
In this study, we used the PHQ-9 diagnostic algorithm to provide an estimate of
current
major depression in the general population. We also used the cut-of score of _ 10 to
estimate the rate of clinically significant depression (Kroenke, Spitzer & Williams,
2001;
Pirkis et al., 2009). The PHQ-9 was chosen as a measure of depression over the
established
21-item Beck Depression Inventory-II (BDI-II; Beck, Steer & Brown, 1996) foremost
because of length, but also due to copyright issues. Strong associations have been
found
between the PHQ-9 and the BDI-II in various populations, indicating a convergent
validity

between the instruments (Dum et al., 2008;Martin et al., 2006; Titov et al., 2011).
Anxiety disorders
The 7-itemGeneralized Anxiety Disorder Scale (GAD-7; Spitzer et al., 2006) was
included
as a questionnaire regarding anxiety disorders in general. It is a 7-itemmeasure,
with items
scored 03, and a total score of 21. Originally developed as a screening tool for
GAD, the
GAD-7 has also proved to have good sensitivity and specificity as a screener for
panic disorder,
social anxiety disorder and post-traumatic stress disorder (Kroenke et al.,
2007).While
the cut-of of 10 is optimal for detecting GAD, a cut-of of 8 has been found to
maximize
sensitivity (77%) and specificity (82%) when detecting any anxiety disorder
(Kroenke et
al., 2007). In this study, we used this cut-of (_ 8) to provide an estimate of
clinically
significant anxiety. Internal consistency for the GAD-7 is excellent (Cronbachs _ D :
92)
and with a good test-retest reliability of r D :83. In addition, convergent validity of
the
GAD-7 has been shown to be good, as demonstrated by its correlations to the Beck
Anxiety
Inventory, r D :72, and the anxiety dimension of SCL-90, r D :74 (Kroenke et al.,
2010).
Similarly to the PHQ-9, the GAD-7 has been shown to be valid in the general
population
(Lowe et al., 2008). The GAD-7 was chosen over other measures of anxiety due to
its short
length, free availability, but also because of its possibility to screen for anxiety
disorders in
general (Lowe et al., 2008).
Generalized anxiety disorder
To get an estimate of the prevalence of GAD, the Generalized Anxiety Disorder
Questionnaire-IV (GAD-Q-IV; Newman, Zuellig & Kachin, 2002) was used. It is a
questionnaire that mimics the structure of the DSM-IV diagnosis of GAD. The
instrument
is a checklist that contains questions regarding excessive worry during the last 6
months.
It also lets the participant register symptoms which are common among patients
with
GAD, and lets the respondent give an account over his or her worry areas or topics.
The
last question is about impact. A cut-of of 5.7 points (83% sensitivity and 89%
specificity)
on the GAD-Q-IV has been reported to indicate the presence of GAD (Newman,
Zuellig
& Kachin, 2002). Newman, Zuellig & Kachin (2002) proposed a cut-of of 9.0 points
(70%

Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 6/18

sensitivity and 96% specificity) to get greater certainty that only persons with GAD
are
identified. In this study, respondents were instructed to skip the rest of the GAD-QIV
questions if they answered no to the first question about experience of excessive
worry
which might have lead to existing GAD cases not being identified. Skipped items
were
coded as zero. The cut-of score of 5.7 was used in this study to provide an estimate
of the
prevalence of GAD.
Health-related quality of life
The EuroQol (EQ-5D; EuroQol Group, 1990) was used to assess health-related
quality
of life (HRQoL). The instrument contains five dimensions: mobility, self-care, usual
activities, pain/discomfort and anxiety/depression where respondents rate their
current
health on a three-point scale (EuroQol Group, 1990). In addition, there exists a
mean of
converting the scores into a single index score, using a tarif (Dolan, 1997). This
index
score ranges from 0.594 to 1, where full health is 1 and being dead is 0 (a
negative value
represent a health condition considered worse than death). As there is no tarif for
Sweden,
we used the tarif from the UK (Dolan, 1997) which is commonly used in research
from
Sweden (Burstrom, Johannesson&Diderichsen, 2001).

RESULTS
Demographic data are illustrated in Table 1. There were some gender diferences in
this
data, as women (56.5% had post-secondary education) were more educated than
men
(45.3% had post-secondary education).Women also had more experience of
treatments
for worry and for psychiatric problems in general. Moreover, the rate of experience
of
treatment for any psychiatric disorder was 52.2% (95% CI: 45.359.1; n D 107)
among
individuals with clinically significant depression or anxiety (n D 205), and 64.9%
(95% CI:
56.773.1; n D 85) among those with major depression or GAD (n D 131).

Prevalence of depression and anxiety disorders

Prevalence rates are illustrated in Table 2. The estimate of clinically significant

depression
(PHQ-9 _ 10) was about double (10.8%) that of major depression (5.2%), using the
diagnostic algorithm. Prevalence rates of anxiety disorders in general and of GAD
were

14.7% and 8.8%, respectively. There were significant gender diferences for all
estimates,
as seen in Table 2. Average scores on the PHQ-9 and the GAD-7 in the entire sample
were
3.70 (n D 1240; 95% CI: 3.443.96) and 3.59 (n D 1266; 95% CI: 3.363.81)
respectively.
On the PHQ-9, women scored higher, 4.21 (n D 683; 95% CI: 3.844.57), than men,
3.07
(n D 557; 95% CI: 2.723.42), t.1238/ D 4:29, p < :001. This was similar for the
GAD-7,
with women scoring 4.13 (n D 704; 95% CI: 3.814.45) and men scored 2.91 (n D
562;
95% CI: 2.623.21), t.1264/ D 5:33, p < :001.
Prevalence rates using stricter definitions
As a mean of having larger certainty that only individuals with the disorder were
identified,
more strict cut-ofs on the PHQ-9 (_ 15) and the GAD-Q-IV (_ 9.0) were employed.
This
resulted in prevalence rates of 4.4% (95% CI: 3.35.6) for depression/depressive
symptoms
and 4.7% (95% CI: 3.55.8) for GAD.
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 7/18

Prevalence of health-related quality of life problems

The most prevalent HRQoL problems were reported in the Pain/discomfort

dimension
where 38.9% of the participants who reported moderate or severe problems. This
was
followed by the Anxiety/depression dimension where the corresponding figure was
34.3%. Prevalence of moderate/severe problems in the other dimensions were less
than 10%. Gender diferences were observed in the dimensions Usual activities and
Anxiety/depression. Details are presented in Table 3. The mean EQ-5D index value
was
0.84 (0.830.85) for all participants (n D 1295). There was a significant diference
where
men reported higher HRQoL (0.87; n D 572; 95% CI: 0.850.88) compared to women
(0.83; n D 723; 95% CI: 0.810.84), t.1293/ D 3:46, p < :001.

Comorbidity

As seen in Table 2, the rate of comorbidity was 8.3% (95% CI: 6.89.9) and 3.1%
(95%
CI: 2.14.1), when using the two diferent definitions. Put diferently, among those
with
clinically significant depression or anxiety, 48.3% (100/207) had comorbid
depression and
anxiety, while the same figure was 28.2% (37/131) among those with major
depression or
GAD. This is illustrated in further detail in Fig. 1.
Patients with comorbid clinically significant depression and anxiety had higher
symptom severity, compared to those with a single diagnosis as measured by the
PHQ-9

(14.91 compared to 8.21) and the GAD-7 (13.00 compared to 8.55). The same was
true for
those with comorbid major depression and GAD (PHQ-9 score 18.81, GAD-7 score
14.17),
compared to those with either of the diagnoses (PHQ-9 score 10.55, GAD-7 score
9.99). All
the diferences were statistically significant (all ts>5.13, all ps<.001).

Efects of depression, anxiety and their comorbidity on

healthrelated
quality of life

HRQoL as measured by EQ-5D index values was consistently lower among

participants
with disorders than those without: Clinically significant depression, 0.54 vs 0.88;
clinically
significant anxiety, 0.61 vs 0.88; major depression, 0.43 vs 0.87; generalized
anxiety
disorder, 0.63 vs 0.86. All diferences were significant (all ts>11.8, all ps<.001).
Among participants with comorbid depression and anxiety, compared to those with
a
single disorder, there were further diferences in health-related quality of life.Mean
EQ-5D
index values were 0.51 (n D 99; 95% CI: 0.450.58) and 0.71 (n D 105; 95% CI:
0.660.75)
for comorbid/not comorbid clinically significant depression and anxiety, and 0.45 (n
D 35;
95% CI: 0.360.54) and 0.63 (n D 90; 95% CI: 0.570.69) for participant with
comorbid
major depression and GAD compared to those with a single diagnosis. These
diferences
were significant (both ts>2.96, both ps<.01). Significant diferences due to
comorbidity
were also observed in EQ-5D dimensions Usual activities and Anxiety/depression for
both
definitions of comorbidity, and also for Pain/discomfort for clinically depressed or
anxious
participants.Details of these analyses are presented in Table 4.
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 8/18
Figure 1 Illustration of prevalence of depression, anxiety and comorbidity. (A) Prevalence
rates of
clinically significant depression (134/1240), clinically significant anxiety (186/1266) and their
comorbidity
(100/1201). Also illustrated are clinically significant depression without anxiety (30/1245) and
clinically significant anxiety without depression (77/1261). (B) Prevalence rates of current major
depression
(65/1240), GAD (112/1269) and their comorbidity (37/1195). Furthermore, current major
depression without GAD (26/1266) and GAD without major depression (71/1267). Note: As the number
of respondents were diferent for various measures, diferent prevalence rates in the figure may not
add
up to exactly the same figure as that given. GAD, Generalized anxiety disorder.

DISCUSSION

This study suggest that, at any given time point, around 17.2% of the Swedish
general population

are experiencing clinically significant depression (10.8%) or anxiety (14.7%) that

likely afect their daily lives. Around 5.2% experienced a current major depressive
episode
and 8.8% had generalized anxiety disorder. Half of those with either clinically
significant
depression or anxiety also had a comorbid disorder. Comorbidity among disorders
was
associated with higher symptomseverity and lower health-related quality of life.
Between half and two thirds of participants with a disorder had treatment
experiences.
This is in line with what was found in the US National Comorbidity Survey
Replication
(NCS-R), where only 51.6% (95% CI: 46.157.2) of 12-month cases received health
care
treatment for depression, and where only 21.7% (95% CI: 18.125.2) were
adequately
treated (Kessler et al., 2003). Furthermore, there are data from a community survey
in
Finland, where the use of health services for mental health was investigated
(Hamalainen
et al., 2008). Among individuals with depression, anxiety disorders, or both, only
34%,
36%, and 59% used health services, respectively. In summary, data fromthe present
study
are in line with treatment consumption studies from other countries, and indicate
that
depression and anxiety disorders are undertreated conditions also in the Swedish
general
population.
This study estimated the point prevalence of major depression in Sweden to be
5.2%.
This figure is in line with the 12 month prevalence rates from the US (6.7%, 95% CI:
6.17.3; Kessler et al., 2005, Australia (6.3%, 95% CI: 5.76.9; Andrews, Henderson
& Hall,
2001) and the Netherlands (5.8%, 95% CI: 5.26.4; Bijl, Ravelli & Van Zessen, 1998).
The
figure 5.2% is also close to the original estimate of 4.7%, from the 1957 population
in the
Lundby study (Rorsman et al., 1990). When using a stricter definition (only 5% risk
of
detecting false positives), 4.4% of individuals were identified as having major
depression.
This and other prevalence estimates provide further indications that 5.2% is indeed
a
valid estimate of current point prevalence of major depression in Sweden, and
therefore
complements epidemiological research from the Lundby study (Rorsman et al.,
1990) and
the national Swedish Twin Registry (Kendler et al., 2006).

A cut-of of PHQ-9 _ 10 was used to identify clinically significant depression, and

was found among 10.8% of individuals in this study. This rate is similar or somewhat
higher compared to previous estimates using the same definition in the US (8.6%;
Kroenke et al., 2009) and in Canada (8.4%; Patten & Schopflocher, 2009). Our result
on clinically significant depression seems to mirror estimates of any mood
disorder,
e.g., from the NCS-R (Kessler et al., 2005) where this was found among 9.5% (95%
CI:
8.710.3).
We found the point prevalence of clinically significant anxiety in Sweden to be
14.7%,
using the definition of GAD-7 _ 8. This seems similar or somewhat higher than
previous
estimates fromGermany (12.1%; Lowe et al., 2008). The mean GAD-7 score in the
present
study (3.59, 95% CI: 3.363.81) was higher than the average score from the
German
population study (2.95, 95% CI: 2.853.04) (Lowe et al., 2008). The rate of clinically
significant anxiety found in this study can be compared with that of 18.1% for any
anxiety
disorder from the NCS-R (Kessler et al., 2005). Importantly, the GAD-7 is known only
to
identify GAD, social phobia, panic disorder and PTSD (Kroenke et al., 2007). The
NCS-R
estimate did also include specific phobia, which was found in 8.7% of US 12 month
cases
(Kessler et al., 2005). In conclusion, our estimates of prevalence of general anxiety
seem
comparable to other epidemiological studies.
Our estimate of GAD prevalence, 8.8%, using the definition of GAD-Q-IV _ 5.7
(Newman, Zuellig &Kachin, 2002), seemsignificantly higher than in other
epidemiological
studies frome.g., US (3.1%; Kessler et al., 2005) and Australia (2.6%;
Andrews,Henderson&
Hall, 2001). The stricter definition of GAD-Q-IV _ 9.0 (95% specificity) gave an
estimate
of 4.7%, that indicates that the true prevalence in Sweden is probably at least that
high.
Importantly, as noted by Kessler and colleagues (Kessler, Walters & Wittchen, 2004)
in a
review of the epidemiology of GAD, there are uncertainties about the basic
epidemiological
characteristics of GAD that could lead to underestimates of the true prevalence of
GAD
in the general population. There are known complicating factors due to changing
DSM
criteria over time, and the fact that DSM definitions of GAD seemto exclude a
substantial
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 11/18

amount of individuals with chronic worry, tension and nervousness (Kessler, Walters
&
Wittchen, 2004). Kessler,Walters &Wittchen (2004) argued that the true current
prevalence
of GAD in the community could actually be as high as 5 to 8%. Our study has
provided
indications that the prevalence of GAD in the Swedish general population is
probably
within this interval.
The EQ-5D index value obtained in this study (0.84) was identical to that obtained in
a
study that validates the EQ-5D in the Swedish general population (Burstrom,
Johannesson
& Diderichsen, 2001). Absence of reported confidence intervals in Burstrom,
Johannesson
& Diderichsen (2001) prohibits a more detailed comparison, but when comparing
HRQoL
data fromthis study (Table 3) to Swedish normative data, no dimension difers more
than
5.4%. This gives indications that HRQoL data collected in this study are overall
similar to
previous collected data fromSweden.
There are methodological limitations that need to be considered. In this study, we
used
self-reporting, rather than a diagnostic interview, such as the SCID (First et al.,
1997) or the
CIDI (Robins et al., 1988).While the measures used in this study are thoroughly
validated
(Kroenke, Spitzer &Williams, 2001; Newman, Zuellig & Kachin, 2002; Spitzer et al.,
2006),
also for use in the general population (Kroenke et al., 2009; Lowe et al., 2008) we
still consider
this as a limitation. A further limitation is that with the data collected on educational
level it was impossible to interpret whether a respondent had a certain education
ongoing
or completed. This makes the collected rate of 52% with post-secondary education
hard to
interpret. According to national statistics fromStatistics Sweden (Statistics Sweden,
2010),
this figure is 35.5%. This indicates that our data on educational level may not be
valid.
A final important limitation of this study is the response rate of 44.3%, as for
example
compared to Kessler et al. (2005) who had 70.9% response rate. Among community
surveys
using the PHQ-9, our response rate is low in comparison to 64.5% (Martin et al.,
2006),
but higher than in Pirkis et al. (2009) who reported 28.6%. This could have biased
the

prevalence estimates in this study. Importantly, there are indications that

individuals with
mental illness might be more reluctant than others to participate in mental health
surveys
(Allgulander, 1989; Eaton et al., 1992). Based on this, prevalence estimates of
depression
and anxiety disorders in this study would be underestimated, if biased. Future
research
with a similar design to this study should make use of established strategies to
increase the
response rate, for example, by using monetary incentives, using pre-notification and
by
having a shorter questionnaire (Edwards et al., 2007).
Some implications of this study are discussed as follows. The results from this study
complements and corroborates earlier findings from Sweden and other countries by
providing up-to-date prevalence rates. The fact that 17.2% of the population sufer
from
a clinically significant depression or anxiety condition calls for further eforts
regarding
prevention and treatment. This includes both novel and more established
intervention
alternatives. The use of the Internet is one way of enabling evidence-based
interventions
to reach larger proportions of the general population (Munoz, 2010). Internet-based
psychological
treatments seem to be a promising and feasible treatment alternative that may
increase availability of evidence-based treatments for psychiatric disorders such as
depresJohansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 12/18

sion and anxiety (Andersson, 2009; Hedman, Ljotsson & Lindefors, 2012). Future
challenges
include establishing means of delivering such treatment in regular health-care
(Hedman et
al., 2013), but also on national level with preserved efcacy (Calear et al., 2009).
A further implication regards the significant amount of comorbidity between
depression
and anxiety disorders identified in this study (see Fig. 1). The large overlap calls for
alternatives to disorder-focused assessments and treatments that address
transdiagnostic
factors, such as emotion regulation deficits (Aldao, Nolen-Hoeksema & Schweizer,
2010;
Mennin, McLaughlin & Flanagan, 2009). This could potentially enable assessment
that
is grounded in experimental research and that provide an opportunity for treatment
alternatives that target these processes (e.g., Farchione et al., 2012; Johansson et
al., 2012;
McEvoy, Nathan & Norton, 2009).Hence, transdiagnostic treatment approaches
seemas an
important step in addressing psychiatric comorbidity.
Finally, there are indications that positive mental health likely is more than absence

of psychiatric symptoms (Huppert & Whittington, 2003). For example, the absence
of
positive emotions have been found to be a better predictor of mortality than the
presence
of psychological symptoms (Huppert & Whittington, 2003). Also, there are
indications that
disability and lack of social roles are important determinants of psychological
symptoms,
but have less influence on positive well-being. Similarly, paid employment has been
found
to be an important determinant of positive well-being but it seemto have little
influence on
psychiatric symptoms (Huppert & Whittington, 2003). Therefore, future
epidemiological
research that aims to understand the whole picture of human health seems to
require assessments
that go beyond mere symptoms (Cloninger, 2006;Huppert&Whittington, 2003).

CONCLUSIONS
The findings reported here provide updated prevalence rates from the Swedish
general
population. Depression, anxiety and their comorbidity are undertreated conditions
that
are associated with lower quality of life. This study adds to existing evidence that
these
conditions are clearly major health problems in Sweden, that need further eforts
regarding
preventive and treatment interventions.

ACKNOWLEDGEMENTS
We would like to thank ElinoreHellqvist for help during the data collection.

ADDITIONAL INFORMATION AND DECLARATIONS

Funding

This study was sponsored in part by a grant to Gerhard Andersson from Linkoping
University. The funders had no role in study design, data collection and analysis,
decision
to publish, or preparation of the manuscript.

Grant Disclosures

The following grant information was disclosed by the authors:

LinkopingUniversity.
Johansson et al. (2013), PeerJ, DOI 10.7717/peerj.98 13/18

Competing Interests

Gerhard Andersson is an Academic Editor for PeerJ.

Author Contributions

_ Robert Johansson conceived and designed the experiments, analyzed the data,
wrote the
paper.
_ Per Carlbring, A sa Heedman and Gerhard Andersson conceived and designed the
experiments, performed the experiments, analyzed the data, wrote the paper.
_ Bjorn Paxling analyzed the data, wrote the paper.

Human Ethics

The following information was supplied relating to ethical approvals (i.e. approving
body
and any reference numbers):
Approval for the study was obtained from the institutional review board at the
Department of Behavioural Sciences and Learning, Psychology section, Linkoping
University, Sweden. The verbal approval was attained during a meeting with the
board at LinkopingUniversity